PA Policies

Certain prescription drugs require prior authorization. Please refer to the links below for detailed criteria that must be met before approval can be granted. Once you have read the criteria and you would like to initiate a drug coverage review, you will need to fax a drug coverage review form to the pharmacy benefit manager.

If you need information on a medication that is not listed below, please contact Medco, the State Health Plan's pharmacy benefit manager, at 1-800-336-5933.

Prescription drugs that require prior authorization for exceeding quantity limits also have detailed policy that must be met before approval can be granted. Please click on the link below for the individual drug criteria that reflect the policies:


Migraine Medications (Imitrex, Zomig/ZMT, Amerge, Maxalt/MLT,
Axert, Frova, Relpax, Migranal NS, Treximet) (PDF, 107 KB)

Proton Pump Inhibitors (Prilosec, Aciphex, Nexium, Prevacid, Protonix) (PDF, 141 KB)

Sedative Hypnotic Agents (Rozerem, Sonata, Ambien, Ambien CR, Lunesta) (PDF, 45 KB)